Chronic stable angina pectoris is due to transit myocardial ischemia. Aspirin, nitrates, beta-adrenoceptor blocking drugs, and calcium channel blocking drugs used alone or in combination with one another are the commonly used drugs for angina pectoris.
Aspirin as an antithrombotic agent is a symptomatic treatment for chronic stable angina pectoris.
Nitrates are used to treat an anginal episode and can be successfully used in prophylaxis by patients with predictable symptoms. With all nitrates, troublesome headache can prevent their use in certain susceptible individuals.
Beta-adrenoceptor blocking drugs, although established as a cornerstone in the treatment of angina, are specifically contraindicated in patients with obstructive airways diseases and severe ventricular dysfunction, and relatively contraindicated in diabetes and in those with peripheral vascular disease, bradycardia or heart block.
Calcium antagonists are certainly effective in angina, achieving their effects by smooth muscle relaxation in the coronary arteries and peripheral circulation, increasing myocardial supply and reducing myocardial work.
Although there is progress in drug combination therapy in angina, which most patients begin treatment with nitrates and a beta-adrenoceptor blocking drug or a calcium antagonist, there is a need of drug for chronic stable angina pectoris which is very effective, can be taken for a long period of time and has very low toxicity.
In view of the problems of relating to the above mentioned drugs, notable efforts have been made to apply herbal Medicine as an alternative to the standard treatment of chronic stable angina pectoris. Traditional Chinese Medicine (TCM) has contributed much in this respect.
U.S. Pat. Nos. 5,288,485 and 5,433,957 refer to an extract from Hypericum erectum thunb for curing or preventing diseases caused by disorder in blood circulation such as angina pectoris.
U.S. Pat. No. 5,776,463 refers to an oral pharmaceutical composition containing petals of borage or extract of borage petals for the prevention and treatment of stress which is associated with circulatory heart diseases including angina.
In addition to Hypericum erectum thunb and borage petals, many other herbal plants have also been used to treat angina. One such plant is Valeriana officinalis latifolia. Yang G Y et al (1994) Reported that 82 patients with angina pectoris had been treated with Valeriana officinalis latifolia, among whom ST-T ischemic changes appeared on ECG in 50 cases before treatment. Its total effective rate for simple angina (without detectable ischemic findings) was 87.80%; the angina with ischemic findings, 88.00%. In addition, it was discovered that Valeriana officinalis latifolia could lower plasma lipids as well. No toxic actions to liver, kidney, and hemopoietic tissue, have been found. (1) Wu Y (1990) reported that in a setting of 267 patients with angina pectoris, 93.3% of the patients treated with xintongkang capsule was effective.
Another herbal preparation called Shenshao tongguan pian was used in treating angina pectoris. In 1990, Hu J X et al. Reported that the Shenshao tongguan pian is composed chiefly of saponin from the stem and leaves of Ginseng and Radix Paeoniae alba, etc. The total effective rate for treating angina pectoris was 94.71%. And the ECG improvement rate was 63.38%. In addition, laboratory examination also revealed that Shenshao tongguan pian could promote the left ventricular output, lower the blood viscosity and inhibit the aggregation of blood platelet. Both acute and chronic toxicity tests showed that Shenshao tongguan pian has no toxicity or side effects.
Kuo-guan granule is another herbal preparation for angina pectoris. Li Y et al. (1990) reported that the changes of the plasma zinc, copper and erythrocyte glutathione peroxidase were measured by atomic absorption spectrometry and DTNB color development in 31 patients suffering from coronary heart disease with angina pectoris before and after taking Kuo-Guan granule for one month. The results indicated that the plasma zinc and erythrocyte glutathione peroxidase were lower and copper was higher in the patients than the normal control group before treatment (P<0.01), the plasma zinc and erythrocyte glutathione peroxidase increased and copper decreased after treatment (P<0.01). These suggest that therapeutic mechanism of Kuo-Guan granule for coronary heart disease with angina pectoris may relate to its regulation on trace elements disturbance in body.
Saponin of Tribulus terrestris was another herbal composition for treating angina pectoris.
Fufang Danshen Pian is a folk prescription of Dan Shen Tablet which indicate for treating chronic stable angina pectoris due to coronary artery ischemia and has been officially listed in the editions of Chinese Pharmacopoeia since 1977 and applied to clinical use for decades.
Fufang Danshen Pian contains multiple active extracts of botanical including Danshen (Radix Salviae Miltiorrhizae), and Sanchi (Radix Notoginseng). Both of the botanical were first documented in Shen Nong Ben Cao Jing (Shen-nong's Herbal Pharmacopoeia) completed in 200. Fufang Danshen Pian also contains synthetic borneol, a version of a natural borneol (Bingpian). Natural borneol was first documented in Tang Ben Cao (Herbal Pharmacopoeia of the Tang Dynasty) compiled around 659.
Li Cheng-zhu et al (1979) reported in (Acta Acad Med Prim Shanghai) on an experimental study of thrombotic inhibition effect of Radix Silviae Miltiorrhizae. Effects on in vitro thrombosis, functions of platelet and coagulation, fibrinolysis were observed in rabbits. After injection of Radix Silviae Miltiorrhizae, 3 links were found to play an important role in inhibition of in vitro thrombosis: (1) inhibition of platelet function; (2) inhibition of coagulation function; and (3) promote fibrinolysis. Of which, the former two mechanisms function more intensely. The results conform to those in the treatment of thrombotic diseases, especially arterial thrombotic diseases.
Chiang W T et al (1982) reported in (Acta Acad Med Prim Shanghai) the effects of “Danshensu” and other two water-soluble components of Salvia miltiorrhiza on dog ischemic myocardium and isolated pig coronary artery. The effect of 3 new water-soluble components i.e. Danshensu (DS-182, D(+)-3,4-dihydroxyphenyl lactic acid), protocathu-aldehyde (PCAD) and an impure diterpene acid (DS-187) isolated from Salvia miltiorrhiza bunge, were compared with those of dipyridamole. Results revealed (1) in mice, DS-182 gave significant protection against hypoxia, whereas PCAD was ineffective; (2) DS-182 could nullify the pituitrin-induced electrocardiographic ischemic ST-T elevation but had no influence on the reduced heart rate. DS-187, PCAD and dipyridamole only showed incomplete protection; (3) in the acutely infarcted dog model prepared by ligation of the anterior descending branch of the left coronary artery, the benefits achieved by intravenous injection of DS-182 proved superior to DS-187 and PCAD in respect to the left ventricular function, left ventricular peak systolic pressure (LVPSP) and left ventricular end diastolic pressure (LVEDP). PCAD, on the contrary, produced adverse effects on LVPSP and LVEDP. Intravenously administered dipyridamole, though it did not change LVEDP, suppressed LVPSP significantly with marked hypotensive effect. All these components of Salvia and dipyridamole significantly reduced the ultimate myocardial infarct size (N-BT assessment); Ds-182 was most effective, dipyridamole and DS-187 the next, while PCAD the least; (4) in the isolated perfused pig coronary artery preparation, DS-182 significantly reduced the resistance of the coronary vessel, whereas either DS-187, PCAD or sodium Tanshinone II-A sulfonate (DS-201), another component of Salvia, increased it. The constrictory action of morphine and propranolol on the isolated coronary artery preparation was antagonized by the prior administration of DS-182. All of these suggested that Danshensu might be the main active principle of Salvia miltiorrhiza in treating ischemic heart disease and that its concomitant use with propranolol or morphine would be beneficial.
Li Cheng-zhu et al (1983) reported in (Chin J Integr Med) the anti-coagulation effect of Radix Silviae Miltiorrhizae. Danshensu is a water-soluble monomer extracted from Radix Silviae Miltiorrhizae. It is also the main ingredient of commercially sold Injection Radix Silviae Miltiorrhizae. The present study proved that Danshensu inhibits thrombosis in vitro, aggregation of platelet (induced by ADP), and internal and external coagulation systems; diminishes the number of platelets and promotes the degradation of fibrin or fibrinogen. The effects peaked 30 minutes after a single injection of 20 mg/kg in rabbits, lasted for 1 hour, and recovered gradually. 4.5 hours after injection, all recovered to normal but thrombosis test in vitro. Chen Zhanghua (1987) reported in Acta Acad Med Prim Shanghai on effects of “Danshensu” on experimental microcirculatory disturbances and plasm lactic acid concentrations. Natural Danshensu is a water soluble monomer extracted from Radix Salviae Miltiorrhizae (RSM). Microcirculatory disturbances in rabbits were induced by intravenous injection of high molecular weight dextran. Natural Danshensu (dosage 4-6 mg/kg) markedly increased the number of capillary vessels in the bulbar conjunctiva, and also decreased the concentration of plasm lactic acid in the rabbits. Mesenteric microcirculatory disorders were produced by local noradrenaline (4 g) drip in mice. Natural Danshensu dilated the arteries and accelerated the speed of blood flow, thus eliminating microcirculatory blood stasis. In our experiments, effects of synthetic Danshensu were observed concomitantly. The results showed that there was no significant difference between natural and synthetic Danshensu in relieving microcirculatory disturbances.
Sun Xi-ming et al (1991) reported a new pharmacological action of an extract of Danshen (Salvia miltiorrhiza). The paper reports that an extract of Danshen (Salvia miltiorrhiza) which contains the sodium salts of D(+)-(3,4-dihydroxy phenyl) lactic acid was found to possess a new pharmacological action of decreasing the biosynthesis of cholesterol in cells and anti-lipoprotein oxidation, by cell cultural studies. When compared with the control, its electrophoretic migration rate was markedly lowered and MDA content and cytotoxicity decreased obviously. These results indicated that salts of D(+)-(3,4-dihydroxy phenyl) lactic acid may be effective in the prevention and treatment of atherosclerosis.
Zheng Ruo-xuan et al (1992) reported in (Chin J Integr Med) the preservation effect of Radix Silviae Miltiorrhizae on myocardial ischemia induced by coronary ligation in mice. Obvious preservation effect on acute myocardial ischemia in mice by coronary ligation could be obtained after i.p. water-extract of Radix Silviae Miltiorrhizae (5 g crude drug/kg). S-T segment elevation on ECG due to myocardial ischemia in the treatment group was much lower, ischemic size of the left ventricle was smaller and the survival rate was higher when compared with the control.
Wu Yao-zhong et al (1995) reported in (Acta Nanjing Univ Trad Chin Mater Med) on effects of Radix Silviae Miltiorrhizae in promoting blood circulation by removing blood stasis. Pharmacological research of Radix Silviae Miltiorrhizae is common. However, rheological studies on Radix Silviae Miltiorrhizae by assessing PGI2, ET, and TXA2 produced by platelet are seldom. Influence of Radix Silviae Miltiorrhizae on thrombosis, changes of PT, KPTT, FG, ESR and HCT, and aggregation of platelet in rabbits are evaluated in the present study. Conclusions are that Radix Silviae Miltiorrhizae reduces the synthesis of TXA2 and decreases the effects of enhancement of platelet aggregation and thrombosis.
Shi Lin et al (1990) reported in (Acta Pharmcol Sin) on the effects of total saponins of Panax Notoginseng on increasing PGI2 in carotid artery and decreasing TXA2 in blood platelet. Total saponins of Panax notoginseng (PNS) were given orally 100 mg/(kg·day) to rabbit for 8 wk. Aortic atherosclerotic plaque formation was restrained as compared that of to the control group. Radioimmunoassay was used to investigate the effects of PNS on the contents of prostacyclin in carotid artery and thromboxane A2 in rats' blood platelet. Oral administration of PNS 25, 50, 100 mg/(kg·day) for 10 days caused an increase of prostacyclin in carotid artery and a decrease of thromboxane A2 in blood platelet as compared with the control group. These results showed that the anti-atherosclerotic action of PNS may be a result of the correction of the imbalance between prostacyclin and thromboxane A2.
Li Xing et al (1990) reported in (Acta Pharmacol Sin) the Protective effects of Panax Notoginseng saponin on experimental myocardial injury induced by ischemia and reperfusion in rats. Effects of total saponin of Panax Notoginseng (PNS) and purified ginsenoids Rb1 and Rg1 from PNS on myocardial injury induced by cardiac ischemia and reperfusion were studied using rat hearts in situ and in vitro. In pentobarbital-anesthetized rats, PNS pretreatment (100 and 200 mg/kg) provided significant reduction in myocardial infarcted size after left descending coronary artery ligation (40 min) and reperfusion (120 min) in comparison with the control. PNS 12.5 and 25 mg/L, Rb1 10 mg/L and Rg1 110 mg/L significantly decreased cardiac CPK release, attenuated myocardial Ca++ accumulation, reduced malondialdehyde (MDA) production and prevented reduction of superoxide dismutase (SOD) activity in comparison with the control in perfused isolated rat, hearts with global ischemia (40 min) and reperfusion (15 min) The results showed that PNS, Rb1 and Rg1 prevented cardiac ischemia and the action was considered to be related to the inhibition of lipid peroxidation.
Huang Cong et al (1991) reported in (Chin Bull Pharmacol) the effects of Panax Notoginseng Saponin on myocardial ischemia and reperfusion injury in conscious rabbits. The effects of Panax Notoginseng saponin (PNGS) on myocardial ischemia and reperfusion injury in conscious rabbits were studied with observation of changes in electrocardiogram (ECG), the activities of creatine phosphokinase (CPK) and lactate dehydrogenase (LD) and the size of ischemic area. PNGS at the dose of 50 mg/kg and 100 mg/kg significantly reduced the size of myocardial ischemic area. These results suggested that PNGS have the protective effects on myocardial ischemia and reperfusion injury.
Mo Qi-xian et al (1987) reported in (Propriet Trad Chin Med Res) the dynamics of 3H-Borneol. In order to highlight the mechanism of inducing resuscitation of Borneol aromaticity, dynamics of 3H-Borneol were conducted by intraveneous injection and oral administration. The results revealed that the half-life time was 2.8 min after a single intraveneous injection of 3H-Borneol. It suggested that the drug distributed rapidly to the relevent organs and tissues after administration and produced prompt effect. In vivo distribution concentrated on organs and tissues which are abundant in blood flow, such as heart, lung, liver, kidney and brain, etc. This provided clinical application certain theoratical basis. Since the diminishing half-lifetime was 5.3 hours after oral administration of the drug, this suggested that oral Borneol could not lead to accumulation, but poor bioavail-ability. Further studies should be taken to discusse the relationship with drug dose and dosage form.
Chen Tie-feng et al (1990) reported in (Acta Pharmacol Sin) the enhancement of absorption of tetramethylpyrazine by synthetic borneol. Sprague-Dawley rats were given ig tetramethylpyrazine phosphate (TMP) 5 mg/kg with or without previous borneol 5 mg/kg. The plasm TMP concentrations were analysed by GC method, and the data were treated by NONLIN program. The Cmax were 931 and 562 ng/ml, respectively, (p<0.01); while the AUC were 68849 and 37174, respectively, (P<0.05). It is suggested that the borneol enhances the absorption of the TMP but not in elimination.
Xu Wei et al (1995) reported in (Pharmacol Chin Med Clin) the effect of menthol and borneol on the distribution of sulfadiazine sodium and Evan's blue in the rat and mouse brain. Menthol (1.5 g/kg, ig) and Borneol (1.5 g/kg) prolonged the sulfadiazine sodium distribution half-life t1/2 in rats. The above dosage of menthol and borneol given orally also increased the concentration of sulfadiazine sodium in the rat brain. Menthol (ig 0.5 g/kg for 3 days) and borneol (ig 0.5 g/kg for 3 days) promoted the concentration of Evan's blue in the mouse brain, but the value of concentration was significantly lower than that of the mice suffering from the ischemia-reperfusion injury. The results suggested that the menthol and borneol could enhanced the sulfadiazine sodium transfer in brain-blood barrier with no damage to brain-blood barier.
In the United States, coronary atherosclerotic heart disease is the commonest cause of cardiovascular disability and death.
Atherosclerosis is an arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large and medium-size arteries. The condition begins as a fatty streak and gradually builds to a fibrous plaque or atheromatous lesion. The blood vessel walls become thick, fibrotic, and calcified. The artery lumen narrows. Many atherosclerotic plaques remain stable or progress gradually. Others may rupture resulting in hemorrhage, platelet activation, and thus intravascular thrombosis. Coronary thrombosis causes partial or complete vessel occlusion, impairs blood flow, thus leads to unstable angina or myocardial infarction. Alternately, the ruptured plaques may become restabilized, often more severe stenosis.
Exercise and mental stresses increase myocardial oxygen demand. Under normal physiological condition, increased myocardial oxygen demand is met by the arterioles dilating thus increasing blood flow. In the presence of atherosclerosis, the arterioles may dilate maximally to meet basic demand. Such dilated arterioles may be unable to meet the increased myocardial oxygen demand. When oxygen demand exceeds oxygen supply, the ischemia of myocardium occurs. Alternately, severe vessel occlusions may limit blood flow thus cause myocardial ischemia. Clinical manifestations of transient myocardial ischemia is angina pectoris which is a paroxysmal thoracic pain, frequently spread to the arms, particularly to the left arm, with or without accompanied by a feeling of suffocating and impending death.
Angina pectoris is subdivided in to two: stable and unstable. Stable angina pectoris is caused by the increased myocardial oxygen demand in most cases. Stable angina thus attacks in the predictable frequency and duration upon provocation which increases myocardial oxygen requirements such as exercise, mental stress, etc. In contrast, unstable angina pectoris attacks without provocation and usually caused by decreased oxygen supply to myocardium. Plaque disruption, platelet plugging, and coronary thrombosis decrease oxygen supply to myocardium.
Angina pectoris is treated with various drugs, surgical procedure, coronary artery bypass graft, balloon-angioplasty, stent placement, etc. Therapy for stable angina pectoris is primarily to minimize myocardial oxygen demand as well as a preventive measure. Therapy for the acute syndrome unstable angina pectoris is primarily to inhibit platelet activation and thrombolysis.
Current therapeutic agents for chronic stable angina pectoris are nitroglycerine, other nitrates, calcium channel blockers, and beta-adrenergic receptor blockers. These drugs, administered alone or in combination with other drugs, alleviate or prevent rather than cure angina.
When angina attacks, nitroglycerine is administered sublingually to alleviate symptoms. Nitroglycerine is also applied to prevent anginal attacks caused by exertion and stress. Nitrates are applied to prevent angina attacks. Nitroglycerine and nitrates mediate their effect primarily by relaxing vascular smooth muscle, reducing myocardial activity, and thus reducing myocardial oxygen demand. The side effects are throbbing headache, dizziness, weakness, orthostatic hypotension, tachycardia, etc.
Beta-adrenergic receptor blockers such as propranolol are applied to prevent angina pectoris by reducing myocardial oxygen requirements during exertion and stress. The major contraindications are bronchospastic disease, bradyarrhythmias, and overt heart failure. In individuals with asthma and other forms of airway obstruction, beta-blockers may worsen their condition.
Calcium antagonists are applied to prevent angina pectoris by reducing the oxygen demand of myocardium. Myocardium is dependent on calcium influx for normal functions. By inhibiting calcium influx, calcium antagonists may relax smooth muscle of the blood vessel, decrease myocardium activity, reduce oxygen demand by myocardium, and thus prevent angina pectoris. Calcium antagonists have adverse side effects. The mild side effects are flushing, edema, dizziness, nausea, etc. Excessive inhibition of calcium influx to myocardium may cause severe side effects such as cardiac arrest, bradycardia, artrioventricular block, congestive heart failure, etc. Combined with beta-adrenergic drugs, the side effects of calcium antagonists are often augmented.
In China, Panax Notoginseng and Radix Salviae Miltorrhizae have been used for treating cardiovascular disease since 200 AD (Shen-nong's Herbal Pharmacopoeia). Panax Notoginseng has been used for treating angina pectoris. Radix Salviae Miltiorrhizae has been used for promoting blood circulation and dispersing blood stasis. Numerous preclinical and clinical studies demonstrate the efficacy and safety of Panax Notoginseng and Radix Salviae Miltiorrhizae.
Traditional Chinese medicine is the mixture of several herbs requiring decoction. A modified form of Chinese medicine for treating coronary heart disease is Dan Shen tablet. Dan Shen tablet is a large unctuous ball, often as large as 1 cM in diameter. Dan Shen tablets are made of the extract of Radix Salviae Miltiorrhizae, powder of Panax Notoginseng and synthetic borneol, have been listed in the Chinese Pharmacopoeia since 1977, and have been used to treat cardiovascular disease for decades.
The disclosed Danshen pill (DSP) or called cardiotonic pill is a generation Chinese medicine for coronary heart diseases. Chinese medicine consists of various herbs which vary from prescription to prescription in regard to the type of herbs as well as the proportion of herbs. To control the quality, DSP is manufactured with the standardized formula. The therapeutic components of DSP are the water-soluble extracts of Radix Salviae Miltiorrhizae 10-30% and sometimes, approximately 20%, the water-soluble extracts of Panax Notoginseng (2-6%), and borneol (1-3%). Furthermore, to alleviate angina quickly, DSP has been manufactured as a small pill which can be dissolved immediately upon sublingual administration, delivered to myocardium quickly, and thus alleviate angina fast.
DSP has been proven to be nontoxic and effective for the prevention and treatment of cardiovascular disease caused by coronary artery ischemia in preclinical and clinical studies. Furthermore, the superior efficacy of DSP to Dan Shen tablets for treating coronary arterial disease has been demonstrated in preclinical as well as in clinical studies.
DSP has been listed in the Supplement Edition of Chinese Pharmacopoeia since 1998, approved by the Chinese Ministry of Health, marketed as a drug in China since 1993, and used by more than five million people.